Health-Care Rationing Takes From the Poor

Published: July 25, 1990

To the Editor:

I agree with William B. Schwartz and Henry J. Aaron in ''The Achilles Heel of Health Care Rationing'' (Op-Ed, July 9) that there are technical problems with Oregon's plan to rank medical services for funding by cost effectiveness. This proposal would limit the type of medical services Medicaid recipients could receive and ''would pay only for care that ranks above a cutoff point determined by the availability of funds.''

The plan would also expand Medicaid eligibility limits and almost double the number of people eligible for Medicaid by raising income eligibility from 58 percent to 100 percent of the Federal poverty level. Simply stated, a fixed amount of money allocated to a state's Medicaid program would be spent either on more costly services for fewer people or less costly services for more people.

The authors state, ''Oregon's plan to deny certain health services to Medicaid patients is the latest and clearest acknowledgment that rationing will be necessary to control the rapid growth of the nation's medical costs.'' The authors appear to support the ''rationing'' plan once its problems can be repaired.

To focus on the fundamental defects of ranking medical services before debating and discussing the impact of the plan concerns me. The plan if put into effect would be a public policy that explicitly denies poor people life-saving medical services available to those who can pay or whose insurance coverage will pay for them.

Part of the problem is that what is being proposed for Oregon is not rationing. Rationing, according to Webster's Third New International Dictionary, is sharing a scarce good or service, as determined by its supply, and made available equally or equitably in accord with need. Rationing is not the same as allocating or providing allowances, both of which imply granting, rather than sharing.

In the Oregon plan, there is no sharing of a scarce service nor would services be based equitably or equally on need. Indeed, it is not medical services that require to be rationed; it is money that is perceived to be in short supply. The Oregon plan is simply an allocation of medical services based on a specified level of funds, with society unwilling to appropriate more money for health care for the poor. Let's call the Oregon plan what it is and stop misusing the concept of rationing to describe an allocation of services based on available dollars.

That is not to deny our serious problem in the costs of health care or the difficult allocation decisions that need to be made. The essential question is whether medical procedures provided to a child will depend on whether that child unfortunately happens to be on Medicaid or is fortunate enough to have parents who can pay for the care. We may well have to limit medical services that are not deemed cost-effective. But are we going to do it by a system of rationing in which we all share equally, or are we explicitly going to limit services only for those who are financially disadvantaged?